Nokea
The mother of a 4-month-old baby girl asks the nurse when should she introduce solid foods to her infant. The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry.
- B. Awakens once for nighttime feedings.
- C. Gives up a bottle for a cup.
- D. Opens mouth when food comes her way.
Correct Answer: D
Rationale: Opening the mouth for food, along with head control and sitting support, indicates readiness for solids around 4-6 months.
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For best pain management, the nurse should give... of acetaminophen every 4 hours as scheduled.
- A. 3.3 mL
- B. 1.9 mL
- C. 5.0 mL
- D. 0.8 mL
Correct Answer: A
Rationale: For a 7 kg infant, 15 mg/kg = 105 mg. At 160 mg/5 mL, 105 mg requires 3.3 mL, providing effective pain relief without toxicity.
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
38-year-old primiparous client is seen in the outpatient obstetric office 2 weeks postpartum after a spontaneous vaginal birth of a full-term infant after rupture of membranes for 16 hours. The client was discharged on day 2, exclusively breastfeeding.
For each assessment finding, click to indicate whether findings from this client's assessment are generally associated with mastitis, endometritis, or could be a sign of both conditions.
- A. Pulse of 105 beats/minute - Both mastitis and endometritis
- B. Feeling chilled, achy, and fatigued - Both mastitis and endometritis
- C. Baby fed pumped breast milk - Mastitis
- D. Pain rating of 4 on a 0 to 10 scale - Mastitis
- E. Foul-smelling lochia rubra at 2 weeks postpartum - Endometritis
- F. Temperature of 101.2° F (38.4°C) - Both mastitis and endometritis
Correct Answer: B,D
Rationale: Tachycardia, chills, aches, fatigue, and fever are systemic signs of infection in both mastitis and endometritis. Feeding pumped milk and localized breast pain suggest mastitis due to milk stasis. Foul-smelling lochia is specific to endometritis, indicating uterine infection.
The parent of an 11-year-old client who has juvenile idiopathic arthritis tells the nurse, 'I really don't want my child to become dependent on pain medication, so I only allow taking the medication when the pain is really bad.' Which information is most important for the nurse to provide this parent?
- A. Giving pain medication around the clock helps control the pain.
- B. The use of hot baths can be used as an alternative for pain medication.
- C. The child should be encouraged to rest when experiencing pain.
- D. Encourage quiet activities such as watching television as a pain distracter.
Correct Answer: A
Rationale: Scheduled pain medication maintains consistent pain control, reduces inflammation, and prevents severe pain episodes in juvenile idiopathic arthritis, improving mobility and preventing joint damage.
A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?
- A. Establish the frequency of headaches.
- B. Ask about a history of delivering large babies.
- C. Examine the client for pedal edema.
- D. Collect a urine sample to screen for protein.
Correct Answer: D
Rationale: Severe headache and hypertension suggest preeclampsia. Screening for proteinuria is critical to confirm the diagnosis and guide urgent management.
Based on the assessment findings, the priority diagnosis suspected is... This diagnosis places the client at risk of...
- A. Mastitis
- B. Engorgement
- C. Blocked milk duct
- D. Inflammatory breast cancer
- E. Abscess
- F. Breastfeeding intolerance
- G. Nipple thrush
Correct Answer: A
Rationale: Mastitis, indicated by fever, localized breast symptoms, and systemic signs, is the priority diagnosis. It risks progressing to an abscess if untreated, requiring prompt intervention.